Systematic review of health literacy champions: who, what and how?

Abstract Health literacy is an important aspect of equitable, safe, and high-quality care. For organizations implementing health literacy initiatives, using ‘change champions’ appears to be a promising strategy. This systematic review aimed to identify the empirical and conceptual research that exists about health literacy champions. We conducted the systematic literature search using MEDLINE, Embase, CINAHL, Scopus, and PubMed, with additional studies identified by searching references and citations of included studies and reviews of organizational health literacy. Seventeen articles were included in the final review (case studies, n = 9; qualitative research, n = 4; quasi-experimental, n = 2; opinion articles without case studies, n = 2). Using JBI critical appraisal tools, most articles had a high risk of bias. Often champions were not the focus of the article. Champions included staff across frontline, management, and executive levels. Only five studies described training for champions. Key champion activities related to either (i) increasing organizational awareness and commitment to health literacy, or (ii) influencing organizational strategic and operational planning. The most common output was ensuring that the organization’s health information materials met health literacy guidelines. Articles recommended engaging multiple champions at varying levels within the organization, including the executive level. Limited funding and resources were key barriers. Two of four articles reported positive impacts of champions on implementation of health literacy initiatives. Overall, few of the articles described health literacy champions in adequate detail. More comprehensive reporting on this implementation strategy and further experimental and process evaluation research are needed to progress this area of research. This systematic review was registered with PROSPERO (CRD42022348816).


INTRODUCTION
Health literacy is an important consideration for any health organization that seeks to provide equitable, safe, and high-quality care. This is clearly demonstrated across a range of health outcomes: low health literacy is associated with higher mortality, morbidity, medication errors, and rates of hospitalization and emergency department visits (Berkman et al., 2011). Though these associations relate to an individual's health literacy (i.e. skills to access, understand, appraise, and use health information and services), we must recognize the critical role that health organizations also play (Nutbeam and Muscat, 2021). For example, organizational structures and resources affect how easily people can navigate a health service, the quality of health information provided to patients, and extent that staff are trained in health literacy concepts and communication skills (Farmanova et al., 2018).
For organizations implementing health literacy initiatives, using 'change champions' appears to be a promising strategy. The Consolidated Framework for Implementation Research (CFIR) defines champions as 'individuals who dedicate themselves to supporting, marketing, and "driving through an [implementation]", overcoming indifference or resistance that the intervention may provoke in an organization' (Greenhalgh et al., 2004;CFIR Research Team-Center for Clinical Management Research, 2022). A recent scoping review identified change champions as one of four critical factors for implementing organizational health literacy interventions (Kaper et al., 2021). Similarly, a 2018 systematic review on the same topic identified the absence of a change champion as one of 13 key barriers (Farmanova et al., 2018). These findings reflect broader healthcare implementation research. For example, reviews show 'generally positive' evidence that champions contribute meaningfully to implementation efforts, and implementation science experts consider 'identifying and preparing champions' an important and highly feasible implementation strategy that should be prioritized (Waltz et al., 2015;Miech et al., 2018;Lennox et al., 2020).
However, there is surprisingly little research defining the concept of 'change champion', and evaluating the impact of change champions on healthcare implementation efforts. Often research on champions is only descriptive in nature, lacking in detail, or the findings are embedded within broader, complex implementation efforts that cannot isolate the individual effect of the champions (Miech et al., 2018;Shea, 2021;Santos et al., 2022). To illustrate, two reviews on champions in healthcare implementation reported that the vast majority of articles only considered champions in terms of presence or absence [more than 90% of 199 articles (integrative review; Miech et al. (Miech et al., 2018)], 71% of 35 articles [systematic review of quantitative research only; Santos et al. (Santos et al., 2022)]. Santos and colleagues' (2022) systematic review of quantitative research related to healthcare champions reported that though champions were related to increased use of healthcare innovations at an organizational level (i.e. policies and processes), there was inconsistent evidence about whether champions were also related to improvements in provider's attitudes and knowledge, use of innovations, and patient outcomes.
This lack of detailed research on champions is also observed in systematic reviews of organizational health literacy, all of which highlight the role of champions, but bear little detail about how to implement this strategy effectively. For example, there was no detail about who champions were, how champions were identified, what training they received, and what activities they engaged in as champions (Farmanova et al., 2018;Lloyd et al., 2018;Kaper et al., 2021). Notably, none of these reviews have assessed the quality of available evidence, rendering it difficult to understand the state of the science in this emerging field and how it can best be progressed.
It is also possible that these reviews of organizational health literacy overlooked some articles relating to health literacy champions given the search terms they used. This oversight is important because the context of health literacy may be different to that of other healthcare champions. For example, health literacy initiatives can vary greatly in scale (e.g. within a specific department vs. initiatives that span across multiple services and sites), and often involve partnership across disciplines, professions, sectors, and community organizations .
To capture the state of the literature and identify evidence to inform practice relating to health literacy champions, we undertook a systematic review to identify the empirical and conceptual research that exists about health literacy champions, including descriptive accounts (e.g. of their roles, responsibilities, selection, and training), evaluations of training and implementation, and relevant models and theoretical frameworks (Munn et al., 2018). Although we can think about health literacy champions as including people who operate across sectors or services, and individuals who are exemplars of health literate practice, in this study we focus on health literacy champions who seek to improve the health literacy practices of other staff members within their organization.

Contribution to Health Promotion
• Health literacy is important for developing safe and accessible health promotion initiatives and resources. However, uptake of health literacy practices within organizations is often poor. • Champions may be a useful strategy for improving uptake of health literacy practices within in a health organization. This review identified 17 articles about health literacy champions, most with high risk of bias. • Champion activities focused on: (i) raising awareness and commitment to health literacy; or (ii) changing organizational strategies and processes. Organizations may benefit from having health literacy champions at different levels within the organization, including the executive level. However, more research is needed.

Protocol and registration
This systematic review was registered with the international Prospective Register of Systematic Reviews (PROSPERO) (CRD42022348816). No amendments to the registered protocol were required, except that case study, and text and opinion articles were deemed high risk of bias in line with Burns et al. (Burns et al., 2011) (see in section 2.7). The review is reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses 2020 statement (Page et al., 2021). This study was based exclusively on published literature. As such, no ethics approval was required.

Review question
What empirical and conceptual research exists about health literacy champions, including descriptive accounts, evaluations of champion effectiveness, evaluations of champion training and implementation, and relevant models and theoretical frameworks?

Inclusion and exclusion criteria
For this review, we included English-language articles published in peer-reviewed journals or published books that examined the concept of a health literacy champion. In line with the CFIR definition (CFIR Research Team-Center for Clinical Management Research, 2022), health literacy champions was taken to refer to staff within an organization who are involved in implementation, delivery, or provision of a health literacy initiative that seeks to improve the health literacy practices in other staff members. No limits were set for date of publication. Studies were excluded if they met any of the following criteria: 1. Mentioned the concept of health literacy champion as a future direction only and text about champions was not directly related to aims, methods or results of the manuscript. 2. Concerned with mental health literacy champions only. 3. Involved patient/community/peer-led education initiatives. 4. Focused on health literacy improvement in patient or community populations, rather than improvement in health literacy practices in an organization.
Where possible MeSH search terms were used (see Supplementary Appendix).
Conference abstracts that appeared during the database searching were excluded but potentially relevant full-text articles relating to these conference abstracts were identified and screened. Systematic reviews on organizational health literacy were also identified and examined for any potentially relevant articles. Additionally, a snowballing approach was used which involved searching the reference lists and citations ('cited by' in Google Scholar) of eligible articles.

Study selection process
After duplicates were removed, titles and abstracts were independently screened by two authors (JA and MZ) for full-text screening. All full texts were also independently screened for inclusion by these authors (JA and MZ). Any disagreements during this process were resolved through discussion between study authors.

Data extraction and synthesis
Data for each article that met the inclusion criteria were independently extracted by two authors (JA and MZ). Extracted data was compared by the two authors and any differences were resolved through discussion with KM. Data extracted included year of publication, aims, study setting and design, interventions implemented, details about the health literacy champions (role, responsibilities, selection, training and effectiveness, and any potential facilitators or barriers to successful championship). Following data extraction, patterns across the data were explored and synthesized in narrative form (Popay et al., 2006). Given the lack of quantitative data and limited detail, even in qualitative research, we did not seek to undertake subgroup analyses or sensitivity analyses. Findings about effectiveness were only synthesized for studies with low risk of bias (Boutron et al., 2019).

Quality appraisal
All full texts included in the data extraction process were assessed for risk of bias by two authors (JA and MZ) using standardized critical appraisal tools from JBI (https://jbi.global/critical-appraisal-tools). Depending on the study design, different JBI critical appraisal tools were used. These included the Checklist for Qualitative Research, and the Checklist for Quasi-Experimental Studies (see Supplementary Appendix).
All Text and Opinion articles were considered high risk of bias. For case study designs, as there was no JBI critical appraisal tool for these study types, these studies were assessed as high risk of bias. These categorisations for text and opinion and case study texts are in line with well-established levels of evidence related to risk of bias (Burns et al., 2011).
When articles contained multiple study design components, a checklist was utilized for all study designs relevant to health literacy champions. Using these tools, studies were categorized as: low risk of bias if most criteria were fulfilled and done well, moderate risk of bias if some of the criteria were fulfilled, or high risk of bias if most criteria were not done or done poorly. Discrepancies in ratings between the two authors were resolved through discussion.

Study details
We retrieved 1149 articles from the database searches, and 18 from additional search methods ( Figure 1). After removal of duplicates and screening by title and abstract, 55 full-text articles were screened for full-text inclusion. Articles were excluded if champions were community members rather than staff (n = 7), if they reported on health literacy improvement in patient or community populations, rather than improvement in health literacy practices in an organization (n = 11), or if the review's definition of champion was otherwise not met, that is, the champion did not influence others within their organization (n = 20). Seventeen articles met our inclusion criteria and were included in the final synthesis.

Study characteristics and risk of bias assessment
The 17 studies identified in the review are described in Table 1. With two exceptions, health literacy champions were not the primary focus of the included research articles and were mentioned as one aspect of implementation of a health literacy intervention or initiative. Only two articles focused primarily on health literacy champions (Brach et al., 2014;Sørensen, 2021). These were both of the 'Text and Opinion' article type, with one providing additional case studies (Sørensen, 2021). Overall, nine articles adopted a case study design and provided an account of how organizational health literacy was introduced in an organization, with health literacy champions playing some part in this process (all high risk of bias). Four articles reported qualitative research investigating how health literacy practices (Adsul et al., 2017;Howe et al., 2020) or tools (Mabachi et al., 2016;Kaper et al., 2019) had been implemented within an organization (three low and one moderate risk of bias). Two studies used quasi-experimental designs to evaluate the implementation of a health literacy intervention in clinical settings (O'Neal et al., 2013;Morrison et al., 2021), although effects of champions were not isolated from the broader intervention (one low, one high risk of bias). Five articles were categorized as 'Text and Opinion' (two without accompanying case studies) and primarily provided a conceptual account of how organizations can improve their health literacy practices.

Who were the health literacy champions?
Health literacy champions were most often described in terms of their professional role. For example, champions included nurses (Erlen, 2004;Kaper et al., 2019;O'Neill, 2019;Morrison et al., 2021), physicians (Brach et al., 2014;Erikson et al., 2019;Morrison et al., 2021), pharmacists (O'Neal et al., 2013;Shoemaker et al., 2013), medical residents (Shoemaker et al., 2013), and staff involved in policy, communication and quality improvement (Kaper et al., 2019;Morrison et al., 2021). Another important group were champions in positions of leadership, including at the executive level (Shoemaker et al., 2013;Mabachi et al., 2016;Brach, 2017;Sørensen, 2021). Two studies described champions who were consultants or externally contracted staff with expertise in health literacy (Briglia et al., 2015;Kaper et al., 2019). Champions were also variously described 'emergent' (Erikson et al., 2019;Sørensen, 2021) (i.e. staff who take on a champion role of their own accord due to their high commitment to the cause), or as staff 'appointed' to a champion role (Briglia et al., 2015;Mabachi et al., 2016;Kaper et al., 2019). Sometimes emergent champions worked in services that did not initially value or engage in health literacy practices, for example, (Erikson et al., 2019;O'Neill, 2019). However, this was not always the case. For example, Brach (Brach, 2017) discussed that CEOlevel staff often became health literacy champions in part due to alignment with the organization's mission and goals.

Champion training
Five studies described health literacy training programs for champions, which ranged in duration from a single 2-hr workshop (O'Neal et al., 2013;Vellar et al., 2017) through to 8 months of ongoing training (Allott et al., 2018). Two studies described a continuation of learning through ongoing mentoring and collaborative support from other champions (Vellar et al., 2017;Allott et al., 2018). Of the five studies that included training, only two mentioned specific training in implementation skills in addition to general health literacy knowledge and skills (Finlay et al., 2019;Morrison et al., 2021). Kaper  More than half of the articles (n = 9) did not describe any form of training for health literacy champions, with most of these focusing on emergent champions.

Health literacy champion activities, roles and responsibilities
Key activities (or roles and responsibilities) fell broadly into three categories: increasing health literacy  Generating awareness about health literacy was typically focused within the organization but occasionally extended beyond (Erlen, 2004;Briglia et al., 2015;Erikson et al., 2019;O'Neill, 2019;Sørensen, 2021). This encompassed communicating the change vision and advocating health literacy to organizational leaders. Three articles described that health literacy champions could seek to influence other organizational leaders to support health literacy initiatives or become health literacy champions themselves (Brach, 2017;Erikson et al., 2019;O'Neill, 2019).
Two studies did not provide specific details and simply alluded to the champions leading implementation and advocating for health literacy (Adsul et al., 2017;Allott et al., 2018).

Potential facilitators and barriers to successful championship
Several studies identified the importance of support and commitment to health literacy initiatives from  (Mabachi et al., 2016;Brach, 2017;Allott et al., 2018;Finlay et al., 2019;Howe et al., 2020;Sørensen, 2021). Many also emphasized that health literacy champions cannot act in isolation, and recommended multiple champions at varying levels within the organization (Brach, 2017;Vellar et al., 2017;Howe et al., 2020;Sørensen, 2021). Further, champions can be supported by other groups within the organization; Sørensen (Sørensen, 2021) describes the CDC case study which depicts champions as working in unison with allies (who provide support/vision), and workgroup members (day to day planning and coordination). Some studies described the importance of organizational awareness and commitment to health literacy before appointing health literacy champions (Mabachi et al., 2016), for supportive policies and infrastructure to be in place (Brach et al., 2014), and for a culture that fosters innovation and quality improvement (Sørensen, 2021).
Lastly, limited resources, lack of dedicated personnel and limited funding were often identified as barriers to effective health literacy champions (Shoemaker et al., 2013;Brach, 2017;Howe et al., 2020).
For appointed champions, bolstering commitment to health literacy may also be important. The authors of two studies proposed several examples of strategies that could strengthen this commitment: personal invitation to champion health literacy from a trusted source, that is, academic institution; awards and other incentives; and aligning champion activities with other goals (such as meeting residency requirements) (Shoemaker et al., 2013;Sørensen, 2021). Shoemaker et al. (Shoemaker et al., 2013) also suggested that providing ongoing support from health literacy experts helped strengthen the commitment of health literacy champions.

Effectiveness
Overall, four articles with low risk of bias reported on the effectiveness of champions. This included three qualitative studies and one quasi-experimental study. Two reported positive effects (Howe et al., 2020;Morrison et al., 2021). The remaining two articles reported neutral effects of health literacy champions (e.g. the champion was only one component of the health literacy initiative and was not identified as a critical factor) (Mabachi et al., 2016;Kaper et al., 2019). Both studies reporting positive effects involved emergent champions, and the third study did not report this characteristic; by comparison, the two studies reporting neutral effects involved appointed champions.
The quasi-experimental study explored a health literacy initiative to improve asthma education in a US emergency department (Morrison et al., 2021). Champions were only one component of this initiative, and their unique effects were not reported. Study authors reported an increase in families receiving asthma education over a 12 month period for written (28-52%) and video materials (0-32%), although no statistical analysis was performed. The intervention did not result in changes to emergency department length of stay, length of discharge, or 30 day revisit rates.

DISCUSSION
We identified 17 articles related to health literacy champions that were generally of high risk of bias. These articles provided only very limited detail about champions, in part because the articles focused on multi-component implementation efforts. Champions included staff on the ground (e.g. nurses, physicians, pharmacists), in administrative or management roles (e.g. quality improvement, senior nurses, communication), and in executive leadership roles. Few studies described training for health literacy champions, and those that did provided little detail. Key champion activities related to increasing organizational awareness and commitment to health literacy, influencing strategic and operational planning, and influencing frontline health literacy practices. The most frequently described influence on frontline practices was to ensure that the organization's health information met health literacy guidelines. Articles recommended having multiple champions at varying levels within the organization, including the executive level. Limited funding and resources were identified as key barriers for health literacy champions. Two of four studies with low risk of bias reported that emergent champions may enhance implementation of health literacy initiatives. Further work is needed to isolate the effect of champions from other implementation strategies.
These findings highlight a clear lack of a foundational, rigorous evidence base that health services can draw upon to inform their health literacy champion roles, programs, and training. Champion research in the broader healthcare literature faces similar issues. For example, most studies only report on the presence or absence of a champion, and do not separate the unique effects of champions from broader multi-component implementation efforts (Miech et al., 2018;Lennox et al., 2020;Shea, 2021). To build a stronger evidence base, health literacy champion research must include experimental study designs and process evaluations that focus specifically on the champions themselves. This must also be accompanied by more detailed reporting (e.g. staff involved, training and expected roles). Over time we may then develop a better understanding of why a given health literacy champion initiative may or may not have worked (Powell et al., 2019). This review did identify some promising directions for health services looking to establish health literacy champions. Notably, several articles described having multiple champions working simultaneously in a coordinated way, with some champions being at the executive or senior leadership levels. This finding is consistent with other systematic reviews of health care champions, which reported that these 'network' structures may be more effective than solo champions (Miech et al., 2018). Interestingly, this review identified a mix of 'top-down' health literacy champion networks, such as the CDC model of 'champions', 'allies', and 'workgroup members' described by Sørensen (Sørensen, 2021); and less hierarchical approaches such as Allott and colleagues' (2018) champions who were nested within a community of practice and alliance network that encouraged collaboration and problem-solving with other champions. The Health Literacy Hub in Western Sydney is another useful example of how a community of practice model can support champions. Over a 5-year period, the Hub has grown to more than 1300 members, providing them with health literacy information and tools, and connecting with members via seminars, mailing lists, targeted training, and partnerships or consultation projects (Muscat et al., 2023). The initiative emphasizes the role of trust, co-creation, and partnership synergy in creating an effective and sustainable community of practice. Further work is needed to inform how health services can create their own sustainable networks of health literacy champions that build staff health literacy knowledge and skills, across a variety of health service settings and organizational structures.
Current organizational health literacy resources lack detailed guidance about how to identify, prepare, and support champions. For example, champions are not mentioned in the organizational health literacy responsiveness framework (Trezona et al., 2017) and the 'Ten attributes of a health-literate organization' only briefly mentions the need to 'cultivate health literacy champions throughout an organization' (Brach et al., 2012). The CDC provides some greater detail, advocating that a first step to improving organizational health literacy practices is to establish champions, allies and workgroup members (Centers for Disease Control and Prevention, 2022). Although a stronger evidence base is needed for concrete recommendations, these resources could guide health services to reflect on who their champions might be, the scope of their roles, expected output, and the kind of incentives, training, or support they need. Given this review highlighted that the commitment of champions may waver, the resource could also include reflection on each champion's personal motivation for improving health literacy, and potential incentives to maintain their commitment.
The strengths of this study were that a wide range of 'champion' search terms were included, across multiple databases. Limitations are that only English-language articles were captured. It is also worth noting that there is also some overlap between the concepts of 'leaders' and 'champions' (Damschroder et al., 2022). Studies that reported solely on leadership support for health literacy are not captured in this review. Limitations of the primary studies were that they generally had high risk of bias and champions were often not described in detail. As a result, this review cannot provide definitive conclusions about whether champions were effective, nor in which contexts. Future systematic reviews on this emerging area of research could also consider more detailed risk of bias assessment to highlight how study designs can be further improved.
Despite the potential positive impacts of health literacy champions, this review suggests that more high-quality research on health literacy champions is needed. As a first step, quality can be improved through more comprehensive reporting on health literacy champions, including who the champions are, the training they received, and the tasks they carried out. Further effectiveness-implementation research including quantitative, qualitative, and process evaluation research across multiple sites will also contribute valuable insights into this implementation strategy. Experimental research may be particularly useful for identifying strategies to support appointed champions, such as resourcing and incentives. Engaging multiple champions at varying levels within the organization, including the executive level, is a promising future direction for this area of research.

Supplementary Material
Supplementary material is available at Health Promotion International online.